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Alternative screening strategies to cytology that decrease structural barriers for women in low-resource areas include visual inspection, a low-technology approach based on viewing the cervix with the naked eye after applying acetic acid (VIA) or Lugol’s iodine (VILI); and HPV DNA testing, particularly with simpler, low-cost, rapid tests. HPV DNA testing shows both high specificity and sensitivity and is particularly valuable in detecting high-grade precancerous lesions in women aged 30 years and older. Further, there is a probability that vaginal self-sampling for HPV DNA testing will provide results equal in quality to those from provider-collected cervical specimens, which is important in many settings. Screening remains necessary even with HPV vaccines in use, both because of the unvaccinated population and because the current vaccines do not protect against all oncogenic HPV types. Whether visual inspection or HVP DNA testing is used for primary screening, another vital component of secondary prevention in low-resource areas is the availability of the screen-and-treat approach. This can make screening and treatment available in one or two visits, eliminating the need for multiple visits, which often results in loss to followup. Cryotherapy is a method of treatment that can be used by health care providers at lower-level health centers to immediately freeze and destroy precancerous tissue during the same visit at which visual inspection reveals the lesions. Preventing cervical cancer contributes to reducing gender inequity in health care and to meeting women’s health needs, and is essential for women’s rights. WHO recommendations for target ages and frequency of cervical cancer screening in these settings are the following: • New programs: start screening women aged 30 years and older. • Existing organized programs: should not include women 25 years of age or younger. • If screened only once in lifetime: best ages are between 35 and 45 years. • For women over 50 years old: a five-year screening interval. • For women aged 25 to 49 years: a three-year interval can be considered. • Annual screening is not recommended at any age. • Screening is not necessary for women over 65 years of age with the last two previous screenings negative. Relieve pain and improve the quality of life: palliative care strategies Emphasizing the unfortunate reality, Dr. Dangou posited that the three most significant features of cervical cancer in Africa are: “1. Late presentation, 2. Late presentation, and 3. Late presentation.” This results in lower cure rates, more suffering and death, and more need for palliative care. To counter the problem, countries need to educate health care workers and the public to detect disease earlier. Report of an African Regional Meeting on Cervical Cancer: September 2010 13
WHO recommendations for care for women with late stage cervical cancer include: • Use existing palliative care services or establish new ones, with special attention to pain control. • Ensure that opioid, non-opioid, and adjuvant analgesics, particularly morphine for oral administration, are available. Manage for success: strengthening national management, and monitoring and evaluation strategies Some of the challenges for national cervical cancer programs are a shortage of trained health workers, lack of up-to-date information, and lack of national policies and programs on cervical cancer prevention. Because cervical cancer is caused by an infectious agent that is sexually transmitted, various governmental and other groups must work together as they have not had to in the past, including immunization, sexual and reproductive health, cancer control, child and adolescent health, school health, and health systems strengthening. Finally, Dr. Dangou reviewed the WHO recommendations on cervical cancer prevention, which include: • A comprehensive and integrated approach to cervical cancer prevention and control that includes screening for cervical lesions or HPV infection among adult women and integrating this with other health interventions. • HPV vaccine is one element of a cervical cancer prevention and control strategy. • Because of HPV vaccine cost, critical issues of equity associated with the new vaccine must be addressed. • Preventing cervical cancer contributes to reducing gender inequity in health care and to meeting women’s health needs, and is essential for women’s rights. Welcome Dr. Geoffrey Bisoborwa Country Advisor, Child and Adolescent Health World Health Organization Uganda Country Office Dr. Geoffrey Bisoborwa welcomed the conference participants with a message from Dr. Joachim Saweka, WHO Country Representative for Uganda. He reminded the audience of the harsh statistics on cervical cancer worldwide, including the prediction by WHO that deaths could increase by 80,000 by the year 2030. The two HPV vaccines that have been approved have great potential to prevent an increase in deaths, but there are challenges to delivering the vaccines to the target population, since this group is older than the population targeted for routine childhood immunizations. The Uganda HPV vaccine demonstration project will help guide the MOH in planning for delivery of this vaccine, and other country experiences will also offer valuable lessons. Further, several groups, including the MOH, the Uganda Women’s Health Initiative (UWHI), WHO Uganda Country Office, Makerere University, and PATH Report of an African Regional Meeting on Cervical Cancer: September 2010 14
Page 1 and 2: Report of an African Regional Meeti
Page 3 and 4: Table of Contents Foreword ........
Page 5 and 6: Foreword Ministry of Health of Ugan
Page 7 and 8: Abbreviations ACCP AFRO AOGU CDP EP
Page 9 and 10: Several other countries reported va
Page 11 and 12: Expected Results • Deepened knowl
Page 13: Overview of Cervical Cancer Prevent
Page 17 and 18: Uganda HPV Vaccine Demonstration Pr
Page 19 and 20: HPV Vaccine Demonstration Project G
Page 21 and 22: This approach also presented a numb
Page 23 and 24: The coverage survey also asked pare
Page 25 and 26: Dr. Murokora and the research team
Page 27 and 28: Questions and Answers 1. What were
Page 29 and 30: Country Experiences in Cervical Can
Page 31 and 32: e used for advocacy and communicati
Page 33 and 34: Other initiatives include the follo
Page 35 and 36: • Coordination of services - Stre
Page 37 and 38: Encouraging Results from Expanded S
Page 39 and 40: Questions and Answers 1. Why has Ug
Page 41 and 42: strategies should be compatible wit
Page 43 and 44: The Unseen Forces Guiding the Cervi
Page 45 and 46: Questions and Answers A question ab
Page 47 and 48: Essential materials have been colla
Page 49 and 50: Challenges remain for keeping cervi
Page 51 and 52: Working Groups on Cervical Cancer P
Page 53 and 54: Group 2: Lesotho, Malawi, and Zambi
Page 55 and 56: services. However, the infrastructu
Page 57 and 58: Next Steps Dr. Jean-Marie Dangou Me
Page 59 and 60: Cervical Cancer Prevention Resource
Page 61 and 62: Annex 1: Final Agenda Improved cerv
Page 63 and 64: Agenda Day 1, September 14 8:00 PAR
Page 65 and 66:
Agenda Day 2, September 15 8:30 REV
Page 67 and 68:
Annex 2: List of Participants Camer
Page 69 and 70:
Uganda (continued) Dr. Cecilia Banu
Page 71 and 72:
Uganda (continued) Dr. Lorna Muhirw
Page 73 and 74:
Uganda (continued) Dr. Rachel Seruy
Page 75 and 76:
Annex 3: Cervical Cancer Rates Cerv
Page 77 and 78:
Annex 4: Situation Analysis SITUATI
Page 79 and 80:
SECTION III CERVICAL CANCER PREVENT
Page 81 and 82:
4. TREATMENT AND PALLIATIVE CARE 4.
Page 83 and 84:
Annex 5: Prioritization Exercise PR
Page 85 and 86:
Annex 6: Country Priorities, Activi
Page 87 and 88:
Lesotho Priorities • Advocacy, ge
Page 89 and 90:
Rwanda Priorities • Mass sensitiz
Page 91 and 92:
Uganda Priorities • Training at v
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